Storage.cloversites.com



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|Grocery/Food Stores |$ |Qty |Total |

|Copps/Pick n Save/ Roundys (4%) |25 | | |

| |50 | | |

| |100 | | |

|Festival Foods (3%) |25 | | |

| |50 | | |

| | 100 | | |

|Piggly Wiggly (3%) |25 | | |

| |50 | | |

|Walmart/Sam’s (2%) |25 | | |

| |100 | | |

|Woodman’s (5%) |50 | | |

| |100 | | |

|Gas |$ |Qty |Total |

|Citgo West Wi Ave 10% |25 | | |

|Grand Central Station Shell (10%) |50 | | |

| |100 | | |

|Kwik Trip (5%) |20 | | |

| |50 | | |

| |100 | | |

|Moto Mart (5%) |50 | | |

|Restaurants |$ |Qty |Total |

|Applebee’s (8%) |25 | | |

|Arbys (8%) |10 | | |

|Buffalo Wild Wings (8%) |25 | | |

|Burger King (4%) |10 | | |

|Chili’s (11%) |25 | | |

|Chipolte (10%) |10 | | |

|Chuck E. Cheese (8%) |10 | | |

|Cousin’s Subs (9%) |10 | | |

|Culver’s (10%) |5 | | |

| |10 | | |

|Dairy Queen (3%) |10 | | |

|Dunkin Donuts (3%) |10 | | |

|Fazoli’s (7%) |25 | | |

|Great Harvest Bread (6%) |10 | | |

|Hardee’s (5%) |10 | | |

|IHOP (8%) |25 | | |

|Little Caesar’s (8%) |20 | | |

|McDonald’s (5%) |10 | | |

|Noodles & Co. (8%) |10 | | |

|Olive Garden/Red Lobster (9%) |25 | | |

|Outback Steakhouse (8%) |25 | | |

|Panda Express (8%) |25 | | |

|Panera Bread (9%) |10 | | |

|Papa John’s (8%) |10 | | |

|Papa Murphy’s (8%) |10 | | |

|Pizza Hut (8%) |10 | | |

|Qdoba Mexican Grill (7%) |25 | | |

|Red Robin (9%) |25 | | |

|Starbucks (7%) |10 | | |

| |25 | | |

***SEE OTHER SIDE FOR COMMON PRE-ORDER CARDS***

OFFICE USE ONLY

Amount Received____________

Check # _____________

Cash ______________

Seller______________________

If Items have to be ordered:

Order Pick Up Site:

_____________________

Date order to be picked up:

____________________

I verify that I received the correct amount of scrip as specified on this purchase form.

Signature

_____________________

|Restaurants |$ |Qty |Total |

|Subway (6%) |10 | | |

| |50 | | |

|Taco Bell (5%) |10 | | |

|Texas Roadhouse (8%) |25 | | |

|TGI Fridays (9%) |25 | | |

|Uno (12%) |25 | | |

|Wendy’s (4%) |10 | | |

|Department Stores |$ |Qty |Total |

|JCPenney (5%) |25 | | |

|Kohl’s (4%) – can be used to pay |25 | | |

|Kohl’s credit card | | | |

| |100 | | |

|Macy’s (10%) |25 | | |

| | 100 | | |

|Sears (5%) |25 | | |

|Shopko (3%) – can be used optical |25 | | |

|and pharmacy | | | |

| |100 | | |

|Target (2%) |25 | | |

| |100 | | |

|Music/Movies |$ |Qty |Total |

|Family Video (12%) |10 | | |

|Marcus Theatres (9%) |25 | | |

|Home Improvement |$ |Qty |Total |

|Ace Hardware (4%) |25 | | |

|Fleet Farm (4.76%) |25 | | |

|Home Depot (4%) |25 | | |

|Lowes (4%) |25 | | |

| |100 | | |

|Menards (3%) |25 | | |

|Miscellaneous |$ |Qty |Total |

| (3%) |25 | | |

| |100 | | |

|American Eagle/Aerie (10%) |25 | | |

|Barnes & Noble (9%) |10 | | |

| |25 | | |

|Bath & Body Work(5%) |10 | | |

| |25 | | |

|Best Buy (3%) |25 | | |

| |100 | | |

|Cabelas (11%) |25 | | |

|CVS (6%) |25 | | |

|Dick’s Sporting Goods (8%) |25 | | |

| |100 | | |

|Gordmans (7%) |25 | | |

|iTunes (5%) |15 | | |

| | 25 | | |

|TJ Maxx/ HomeGoods (7%) |25 | | |

|Toys R Us/Babies R Us (3%) | 20 | | |

|Walgreens (6%) – can be used for |25 | | |

|prescriptions | | | |

Make Checks Payable to: SCRIP

*FREQUENTY IN STOCK * FREQUENTY IN STOCK * FREQUENTLY IN STOCK * FREQUENTLY IN STOCK

S TOCK

Scrip Purchase Form

Name________________________________________ Phone ________________ Date ____________

Debt Reduction

OFFICE USE ONLY

Amount Rec’d_________________ Seller _________ Check #______ Cash______

POSSIBLY IN-STOCK** PRE-ORDER CARDS PRE-ORDER CARDS PRE-ORDER CARDS

S TOCK

Updated: 9/30/16

/16

|Gas |$ |Qty |Total |

|BP/Amoco (1.5%) |50 | | |

|Marathon (3%) |25 | | |

|Shell (2.5%) |50 | | |

|Speedway/Super America (4%) |25 | | |

|Miscellaneous |$ |Qty |Total |

|American Girl (9%) |25 | | |

|Bed Bath & Beyond (7%) |25 | | |

|Build A Bear (8%)** |25 | | |

|Cabelas (11%) |100 | | |

|Catherine’/Lane Bryant/Fashion|25 | | |

|Bug (6%) | | | |

|Claire’s/Icing (9%)** |10 | | |

|Cold Stone (8%)** |10 | | |

|Disney (2%)** |25 | | |

| |100 | | |

| |1000 | | |

|Domino’s Pizza(8%)** |10 | | |

|Express (10%) |25 | | |

|Foot Locker (9%) |25 | | |

|Gamestop (3%) |25 | | |

|Great Clips (8%) |25 | | |

|Gymboree (13%) |25 | | |

|Hallmark (4%) |25 | | |

|Jo Ann Fabrics** (6%) |25 | | |

|Lands End (16%) |25 | | |

| |100 | | |

|Limited (9%) |25 | | |

|LL Bean (15%) |25 | | |

|Office Depot (4%)** |25 | | |

| |100 | | |

|Office Max (5%)** |25 | | |

|Old Navy / Gap(14%)** |25 | | |

|Payless Shoes**(13%) |20 | | |

|Pottery Barn/Williams Sonoma |25 | | |

|(8%) | | | |

|Sears (4%)** |25 | | |

|Talbots (13%) |25 | | |

|The Childrens Place (12%) |25 | | |

|Ulta Salon (4%) |25 | | |

Hundreds more retailers can be viewed online at

Let us know if you find a Retailer you want us to order for you!

Contact Geri Younger (Mon-Fri) at 734-8218 or

Dawn Denis at 205-6142

You may place orders online too.

Go to to set up an online account.

• Sign up for PrestoPay online to pay directly from your checking account rather than writing us a check.

• When you pay and place your order online your gift cards will be ready for pickup at Faith/Celebration, or

• Some retailers have eCards that can be paid for online and printed for immediate use – look for the ScripNow! Retailers such as Walmart, Kohls, Best Buy, Barnes & Noble, Home Depot, Applebee’s, Chili’s and many more.

THANK YOU!

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